Host inflammatory response in women with vaginal epithelial abnormalities after pessary use.

BACKGROUND: Vaginal epithelial abnormalities (VEA) are a common complication associated with pessary use. The objective of this study was to determine if there is a host pro-inflammatory response associated with pessary use and VEA. METHODS: Patients wearing pessaries for at least two weeks for the management of pelvic organ prolapse and/or urinary incontinence were screened for eligibility. Vaginal swabs were collected from women with VEA (cases) and without VEA (controls). Cases were matched to controls in a 1:3 ratio. Cytokine analysis of the collected samples was performed using multiplex analysis to determine the concentrations of interleukin (IL)6, interferon alpha 2 (IFNα2), tumor necrosis factor alpha (TNFα) and IL1ß. A cross-sectional analysis was performed, comparing vaginal cytokine concentrations in women with and without VEA. RESULTS: We enrolled 211 patients in this analysis: 50 cases and 161 controls. The median concentrations (pg/mL) of the four cytokines for cases and controls respectively were; IL6: 6.7 (IQR <2.9 [the lower limit of detection, LLD]-14.2) and < 2.9 (LLD) (IQR <2.9 [LLD]-5.5), IFNα2: 8.2 (IQR 6.1-13.9) and 7.9 (IQR 3.9-13.6), TNFα: 15.2 (IQR 6.1-30.4) and 4.68 (IQR <2.3 [LLD]-16.3), IL1ß 195.7 (IQR 54.5-388.6) and 38.5 (IQR 6.7-154.9). The differences in median cytokine levels were statistically higher in cases for IL6, TNFα, and IL1ß (all p < 0.001) compared to controls. Older age (OR: 1.062, 95% CI, 1.015-1.112), lower BMI (OR: 0.910, 95% CI, 0.839-0.986) and presence of VEA at last check (OR: 5.377, 95% CI, 2.049-14.108) were associated with higher odds of having VEA on multivariate analysis. CONCLUSION: Pro-inflammatory cytokines, specifically IL6, TNFα, and IL1ß, are elevated in pessary-wearing patients who have VEA. Additional prospective studies are needed to assess baseline vaginal inflammatory profiles before and after pessary placement to understand VEA formation in pessary patients.

Evaluation of a multimodal analgesic regimen on outcomes following laparoscopic living donor nephrectomy.

Postoperative pain is a significant source of morbidity in patients undergoing living donor nephrectomy (LDN) and a deterrent for candidates. We implemented a standardized multimodal analgesic regimen, which consists of pharmacist-led pre-procedure pain management education, a combination transversus abdominis plane and rectus sheath block performed by the regional anesthesia team, scheduled acetaminophen and gabapentin, and as-needed opioids. This single-center retrospective study evaluated outcomes between patients undergoing LDN who received a multimodal analgesic regimen and a historical cohort. The multimodal cohort had a significantly shorter length of stay (LOS) (days, mean ± SD: 1.8 ± 0.7 vs. 2.6 ± 0.8; p < .001) and a greater proportion who were discharged on postoperative day (POD) 1 (38.6% vs. 1.5%; p < .001). The total morphine milligram equivalents (MME) that patients received during hospitalization were significantly less in the multimodal cohort on POD 0-2. The outpatient MME prescribed through POD 60 was also significantly less in the multimodal cohort (median [IQR]; 180 [150-188] vs. 225 [150-300]; p < .001). The mean patient-reported pain score (PRPS) was significantly lower in the multimodal cohort on POD 0-2. The maximum PRPS was significantly lower on POD 0 (mean ± SD: 7 ± 2 vs. 8 ± 1, respectively; p = .02). This study suggests that our multimodal regimen significantly reduces LOS, PRPS, and opioid requirements and has the potential to improve the donation experience.

Evaluation of cytomegalovirus prophylaxis in low and intermediate risk kidney transplant recipients receiving lymphocyte-depleting induction.

Cytomegalovirus (CMV) is a significant cause of morbidity in kidney transplant recipients (KTR). Historically at our institution, KTR with low and intermediate CMV risk received 6 months of valganciclovir if they received lymphocyte depleting induction therapy. This study evaluates choice and duration of CMV prophylaxis based on donor (D) and recipient (R) CMV serostatus and the incidence of post-transplant CMV viremia in low (D-/R-) and intermediate (R+) risk KTR receiving lymphocyte-depleting induction therapy. A protocol utilizing valacyclovir for 3 months for D-/R- and valganciclovir for 3 months for R+ was evaluated. Adult D-/R- and R+ KTR receiving anti-thymocyte globulin, rabbit or alemtuzumab induction from 8/20/2016 to 9/30/2018 were evaluated through 1 year post-transplant. Patients were excluded if their CMV serostatus was D+/R-, received a multi-organ transplant, or received basiliximab. Seventy-seven subjects met the inclusion criteria: 25 D-/R- (4 historic group, 21 experimental group) and 52 R+ (31 historic, 21 experimental). No D-/R- patients experienced CMV viremia. Among the R+ historic and experimental groups, there was no significant difference in viremia incidence (35.5% vs 52.4%; P = .573). Of these cases, the peak viral load was similar between the groups (median [IQR], 67 [<200-444] vs <50 [<50-217]; P = .711), and there was no difference in the incidence of CMV syndrome (16.1% vs 14.3%; P = 1.000) or CMV related hospitalization (12.9% vs 14.3%; P = 1.000). No patient experienced tissue invasive disease. These results suggest limiting valganciclovir exposure may be possible in low and intermediate risk KTR receiving lymphocyte-depleting induction therapy with no apparent impact on CMV-related outcomes.

Heart Rate and Neurological Outcomes in Patients Undergoing Targeted Temperature Management.

INTRODUCTION: There is a paucity of data evaluating the impact of heart rate (HR) during Targeted Temperature Management (TTM) and neurologic outcomes. Current resuscitation guidelines do not specify a HR goal during TTM. We sought to determine the relationship between HR and neurologic outcomes in a single-center registry dataset. METHODS: We retrospectively studied 432 consecutive patients who completed TTM (33°C) after cardiac arrest from 2008 to 2017. We evaluated the relationship between neurologic outcomes and HR during TTM. Pittsburgh Cerebral Performance Categories (CPC) at discharge were used to determine neurological recovery. Statistical analysis included chi square, Student's t-test and Mann-Whitney U. A logistic regression model was created to evaluate the strength of contribution of selected variables on the outcome of interest. RESULTS: Approximately 94,000 HR data points from 432 patients were retrospectively analyzed; the mean HR was 82.17 bpm over the duration of TTM. Favorable neurological outcomes were seen in 160 (37%) patients. The mean HR in the patients with a favorable outcome was lower than the mean HR of those with an unfavorable outcome (79.98 bpm vs 85.67 bpm p < 0.001). Patients with an average HR of 60-91 bpm were 2.4 times more likely to have a favorable neurological outcome compared to than HR's < 60 or > 91 (odds ratio [OR] = 2.36, 95% confidence interval [CI] 1.61-3.46, p < 0.001). Specifically, mean HR's in the 73-82 bpm range had the greatest rate of favorable outcomes (OR 3.56, 95% CI 1.95-6.50), p < 0.001. Administration of epinephrine, a history of diabetes mellitus and hypertension all were associated with worse neurological outcomes independent of HR. CONCLUSION: During TTM, mean HRs between 60-91 showed a positive association with favorable outcomes. It is unclear whether a specific HR should be targeted during TTM or if heart rates between 60-91 bpm might be a sign of less neurological damage.

Predictors of delayed postoperative urinary retention after female pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Risk factors can be used to determine what patients will develop delayed postoperative urinary retention after female pelvic reconstructive surgery. METHODS: A case-control study was performed including all female pelvic reconstructive surgeries necessitating a voiding trial. All patients passed their previous voiding trial. Cases had an acute encounter for urinary retention. Controls did not have acute postoperative urinary retention. Cases and controls were stratified based on procedure. Demographics, medical/surgical histories, voiding symptoms, urodynamic testing, and intraoperative data were collected. Cases were matched to controls in a 1:3 ratio. Mann-Whitney U and chi-square tests were used for univariate analyses; logistic regression was used to determine predictors of delayed postoperative urinary retention (DPOUR). RESULTS: A total of 1219 patients underwent pelvic reconstructive surgery that met eligibility; 51 cases of DPOUR (4.3%) were identified and matched with 153 controls without postoperative urinary retention. Of the procedures performed, 41.2% had prolapse surgery, 10.3% had incontinence surgery, and 48.5% had both prolapse and incontinence surgery. There were no differences between cases and controls in age, race, prior surgery, medical comorbidities, prolapse stage ≥ 3, voiding symptoms, and surgical characteristics. Cases had a lower BMI than controls (p < 0.001). There was no difference in preoperative urodynamic variables. Cases had lower percent voided volume on their last voiding trial than controls (90.2% ± 28.6% vs. 110.7% ± 39.5%, respectively; p = 0.001); however, clinically we consider a voided volume of two-thirds or greater of the instilled volume to be a normal result. CONCLUSIONS: DPOUR is an uncommon postoperative event. Demographic and clinical factors and urodynamic findings were unable to predict DPOUR. Percent voided volume on voiding trial was greater in controls.

A comprehensive model for pain management in patients undergoing pelvic reconstructive surgery: a prospective clinical practice study.

BACKGROUND: Postoperative opioid prescription patterns play a key role in driving the opioid epidemic. A comprehensive system toward pain management in surgical patients is necessary to minimize overall opioid consumption. OBJECTIVE: This study aimed to evaluate the efficacy of a pain management model in patients undergoing pelvic reconstructive surgery by measuring postdischarge narcotic use in morphine milligram equivalents. STUDY DESIGN: This is a prospective clinical practice study that included women undergoing inpatient pelvic reconstructive surgery from December 2018 to June 2019 with overnight stay after surgery. As a routine protocol, all the patients followed an enhanced recovery after surgery protocol that included a preoperative multimodal pain regimen. Brief Pain Inventory surveys were collected preoperatively and on postoperative day 1. Brief pain inventory and activities assessment scale scores were collected at postoperative week 1 and postoperative weeks 4-6 after surgery. Patients were discharged with 15 tablets of an oral narcotic using an electronic prescription for controlled substances software platform, which is mandated in the state of Connecticut for all controlled substances, prescriptions, and refills. Patients were called at postoperative week 1 and postoperative weeks 4-6 to answer questions regarding their pain, the number of remaining narcotic tablets, and patient satisfaction regarding pain management. Patient electronic medical records and the Connecticut Prescription Monitoring and Reporting System were reviewed to determine whether patients received narcotic refills. Primary outcome was postdischarge narcotic use measured in morphine milligram equivalents. Secondary outcomes evaluated refill rate, brief pain inventory and activities assessment scale scores, and patient satisfaction with pain management. Descriptive statistics were described as mean and standard deviation and median and interquartile range. Bivariate comparisons used Spearman's rho (ρ) with α=0.05. RESULTS: A total 113 patients were enrolled; the median (interquartile range) morphine milligram equivalent prescribed (including refills) was 112.5 (112.5-112.5). The median postdischarge narcotic use was 24.0 (0-82.5) morphine milligram equivalent, which is equivalent to fewer than 4 oxycodone (5 mg) tablets. About 75% of our participants required fewer than 11 oxycodone tablets. The median unused morphine milligram equivalent was 90.0 (45-112.5). 81.4% (92/113), and 83.2% (94/113) of patients at postoperative week 1 and postoperative weeks 4-6, respectively, reported being satisfied or extremely satisfied with their postdischarge pain control. About 88.5% (100/113) of patients felt that the number of opioids they were discharged with was sufficient for their pain needs at the postoperative 1 and postoperative weeks 4-6 time points. At postoperative weeks 4-6, 19.5% of patients said that they filled the narcotic prescription but did not use any of the pills. The overall refill rate was 10.6% (12/113). All patients who needed a refill described the refill process as easy. In-hospital narcotic use was not predictive of postdischarge narcotic use (ρ0.065, P=.495). Patients reported median brief pain inventory scores for "average pain" of 0 (no pain) at postoperative week 1 and postoperative weeks 4-6; however, the scores did not clinically correlate with postdischarge narcotic use. Activities assessment scale scores were not correlated with postdischarge narcotic use. CONCLUSION: Most patients after pelvic reconstructive surgery used fewer than 11 oxycodone (5 mg) tablets, averaging less than 4 tablets, with a third of patients not requiring any opioids. Pain and activities scores did not correlate with narcotic use. A minimal number of opioids can be prescribed because the secure electronic prescribing system allows for convenient electronic refill if required. Our practical and comprehensive pre- and postoperative protocol for pain management minimizes opioid consumption in addition to maximizing patient satisfaction.

The window is wide: flexible timing for vitrified-warmed embryo transfer in natural cycles.

RESEARCH QUESTION: What is the optimal timing for transfer in natural cycle vitrified-warmed embryo transfers (NC-VET)? DESIGN: This retrospective cohort study uses data from a large university-affiliated IVF clinic. The study included 341 NC-VET cycles with autologous oocytes and non-preimplantation genetic testing, vitrified embryos from January 2013 to September 2017. Each cycle was classified by timing of embryo transfer in relation to LH surge ≥20 IU/l. Group 1: LH ≥20 IU/l one day and blastocyst was transferred 6 days later; Group 2: LH ≥20 IU/l two consecutive days and blastocyst was transferred 6 days after the initial surge; Group 3: LH ≥20 IU/l two consecutive days and blastocyst was transferred 7 days after the initial surge. The primary outcome was ongoing pregnancy rate (OPR). The secondary objective was to compare OPR in relation to serum oestradiol dynamics and progesterone concentration (according to threshold 1.0 ng/ml) 6 days prior to embryo transfer. RESULTS: OPR were similar for all three groups (66.8%, 65.0%, 62.9% for Groups 1, 2 and 3, respectively). When stratified according to oestradiol and progesterone, no significant differences were noted in OPR. CONCLUSIONS: The results suggest that the timing of blastocyst transfer in a natural cycle after LH surge is flexible within 24 h. Outcomes are equally good with day of embryo transfer 6 or 7 days after LH surge date. Oestradiol dynamics and progesterone concentration 6 days prior to NC-VET did not have a significant impact on OPR.

Randomized double-blind trial of short- versus long-acting analgesia at the sacrospinous ligament.

INTRODUCTION AND HYPOTHESIS: Pain control is a key component of postoperative care; our objective was to evaluate if use of long-acting local anesthesia at the sacrospinous ligament leads to decreased postoperative pain versus short-acting local anesthesia in patients undergoing sacrospinous ligament fixation. METHODS: Women ≥ 18 years old undergoing sacrospinous ligament fixation to treat pelvic organ prolapse were eligible to participate in this randomized trial. Enrolled patients were randomized 1:1 to one of two study arms: (1) lidocaine arm (LA) or (2) liposomal bupivacaine arm (LBA). Patients in the LA received 30 ml 0.5% lidocaine with 1:200,000 epinephrine local injection at the sacrospinous ligament. Patients in the LBA received 20 ml 1.3% bupivacaine liposomal mixed with 10 ml 0.5% bupivacaine at the sacrospinous ligament. All patients received 50 ml 0.5% lidocaine with 1:200,000 epinephrine for anterior and/or posterior colporrhaphy. The primary outcome of this study was postoperative buttock pain. RESULTS: Of the 37 patients enrolled, 33 completed study procedures. Mean age (± SD) was 62.3 years (± 11.6) in the LA and 66.8 years (± 14.4) in the LBA (p = 0.32). All participants underwent sacrospinous ligament fixation; the rate of concomitant procedures did not differ between study arms. Visual analog scale scores for buttock-specific pain were compared between arms at 1, 3, 6, 12, 24, 36, 48, 72, 96, and 120 h postoperatively, and no differences were found. CONCLUSIONS: Use of long-acting local analgesia at the sacrospinous ligament at the time of sacrospinous ligament fixation does not provide any benefit over short-acting local analgesia.

The value of fixed rasburicase dosing versus weight-based dosing in the treatment and prevention of tumor lysis syndrome.

BACKGROUND: Rasburicase is a recombinant urate oxidase enzyme used for the treatment and prevention of tumor lysis syndrome. Our objective was to assess the efficacy of indication-based, low-dose rasburicase administration compared to the Food and Drug Administration-approved weight-based dosing. METHODS: This was a retrospective cohort study utilizing data from a tertiary medical center including patients admitted from 2012 to 2016, who received at least one dose of rasburicase. The primary outcome was achieving a uric acid level less than 7.5 mg/dl after a single dose of rasburicase in the preprotocol (Food and Drug Administration-approved weight-based dosing) and postprotocol (indication-based, low-dose) groups. Secondary outcomes included the change in uric acid levels between the pre- and postprotocol groups, adherence to the new institutional protocol, need for repeat rasburicase doses, and a cost analysis. RESULTS: Sixty-four patients received at least one dose of rasburicase between 1 January 2012 and 1 December 2016. Twenty-seven (79.4%) doses in the preprotocol group and 28 (82.4%) doses in the postprotocol group successfully achieved a uric acid level less than 7.5 mg/dl after a single dose of rasburicase (p=1.000). The average total monthly cost of rasburicase was reduced by 59.9% after adoption of the new protocol. CONCLUSIONS: Indication-based, low-dose rasburicase displayed significantly more value when compared to weight-based dosing as shown by achieving cost savings without compromising clinical efficacy.

Rotational and linear head accelerations from taekwondo kicks and punches.

The purpose was to compare rotational and linear head accelerations as a result of taekwondo kicks and punches. Taekwondo athletes executed five repetitions of the turning kick, spinning hook kick, hook punch, straight punch, and jab punch to a Hybrid III Crash Test Dummy head-neck complex. A tri-axial accelerometer and an angular rate sensor were mounted inside the Hybrid III head to measure resultant linear (RLA) and rotational accelerations. The Hybrid III was fixed to a height-adjustable frame and fitted with protective taekwondo headgear. Dummy head height was positioned to each participant's standing height. Acceleration data were processed in accordance with SAE J211-1.There was no significant multivariate difference in RLA but the effect was not clear. Univariate follow-up analysis showed a significant difference in RLA but the effect was also not clear. There was no difference in rotational acceleration. The highest RLA and rotational acceleration were produced, in order, by the turning kick, hook kick, hook punch, straight punch, and jab. These data are clinically important as they provide a better understanding of the biomechanical injury measures and support for improved headgear testing methodology.

Decreasing postoperative narcotics in reconstructive pelvic surgery: a randomized controlled trial.

BACKGROUND: Postoperative pain control is crucial to any successful recovery plan. Many currently used medication regimens are narcotic-focused. OBJECTIVE: The objective of our study was to evaluate the efficacy of a multimodal pain regimen after pelvic reconstructive surgery. STUDY DESIGN: The primary outcome measure was narcotic use. Secondary outcomes included pain, nausea, and constipation. Patients were randomized to either usual care postoperative treatment or multimodal pain regimen. Usual care included no specific preoperative or intraoperative medications, and postoperative narcotics with ibuprofen. Multimodal pain regimen included preoperative and postoperative celecoxib, gabapentin, intraoperative and postoperative intravenous and oral acetaminophen and ibuprofen, and narcotics as needed. All narcotics were converted to milligram equivalents of oral morphine for standardization according to Centers for Disease Control and Prevention guidelines where conversion factors for oral hydrocodone = 1, oral oxycodone = 1.5, and oral hydromorphone = 4. Patients were given the validated Brief Pain Inventory survey preoperatively (baseline), at postoperative day 1, and 1 week postoperatively. At 1 week, bowel function and narcotics usage was assessed. RESULTS: Seventy patients were randomized to the usual care arm and 68 to the multimodal pain regimen arm. Patients in the multimodal pain regimen arm used significantly fewer intravenous narcotics in the operating room (90.7 ± 39.1 mg vs 104.6 ± 33.5 mg; P = .026) and while in the hospital (10.8 ± 15.1 mg vs 31.2 ± 29.6 mg; P < .001) and were more likely to use 0 oral narcotics after discharge to home (34.8% of patients vs 10.6%; P = .001). Of the patients who did use oral narcotics after discharge to home, there was no difference in amount used between groups (121.3 ± 103.7 mg in the multimodal pain regimen arm vs 153.0 ± 113.8 mg in the usual care arm; P = .139). Total narcotic usage (operating room + hospital + home) was significantly less in the multimodal pain regimen arm of the study (195.5 ± 147.2 mg vs 304.0 ± 162.1 mg; P < .001). There were no significant differences in pain scores between the 2 arms of the study on either postoperative time point. There were no significant differences in antiemetic use while in hospital, consistency of first bowel movement, length of stay, or number of telephone calls to nurses in first 3 weeks postoperatively. CONCLUSION: A multimodal pain regimen in pelvic reconstructive surgery was found to decrease postoperative opioid requirements, while providing equivalent pain control.

Suburethral sling procedures in the United States: complications, readmission, and reoperation.

INTRODUCTION AND HYPOTHESIS: Hospital readmission is increasingly used as a measure of quality care. Our objective was to evaluate the rate of readmission and associated factors in women undergoing suburethral sling placement in the USA. METHODS: This is a cohort study of suburethral sling procedures performed in the USA from 2012 to 2014 using the American College of Surgeons' National Surgical Quality Improvement Program database. The database was queried for suburethral sling procedures. Records were excluded if concomitant surgery had been performed. Patient and surgical characteristics were evaluated for association with readmission using Chi-squared test for categorical variables and Student's t test for continuous variables. All results yielding p < 0.05 were deemed statistically significant. RESULTS: A total of 7,117 suburethral sling procedures were identified. There were 83 (1.16%) hospital readmissions. Those who were readmitted tended to be older (p = 0.011), non-Hispanic (p = 0.04), smokers (p < 0.001), and have an American Society of Anesthesiologists Physical Status Classification System score of 3 or 4 (p = 0.001). A history of bleeding disorder (p < 0.001), congestive heart failure (p < 0.001), or chronic obstructive pulmonary disease (p < 0.001) was associated with readmission. Fifty-four (0.75%) patients underwent reoperation within 30 days of suburethral sling placement. The most common reoperation procedure was sling excision (20 patients). The most common complication was urinary tract infection, which occurred in 189 patients (2.7%). CONCLUSIONS: Suburethral sling placement is a safe procedure with a low rate of readmissions, reoperations, and complications. Consistent with other types of surgery, infection is the most common post-operative complication.

Pressure Injury in a Community Population: A Descriptive Study.

PURPOSE: The purpose of this study was to describe present-on-admission pressure injuries (POA-PIs) in community-dwelling adults admitted to acute care. The specific aims of the study were to (1) measure the prevalence of POA-PIs during a 1-year period; (2) determine prehospital location of patients with POA-PIs; and (3) describe demographics, pressure injury (PI) characteristics, risk factors, and posthospital outcome of community-dwelling adults with PIs admitted to hospital. DESIGN: Retrospective descriptive study. SUBJECTS AND SETTING: The study sample was identified from a PI registry, a database maintained for quality improvement, at an 860-bed urban academic medical center in New England. The majority (n = 1022, 76.1%) were admitted to hospital from the community; and the remaining (23.9%) were admitted from long-term care facilities. METHODS: All subjects were assessed by certified wound nurses. Data were extracted electronically from selected standardized electronic health record (EHR) fields, representing variables of interest. Descriptive statistics were analyzed using percentages, means, and medians. RESULTS: The prevalence of patients admitted to acute care with a POA-PI was 7.4%. Community-dwelling subjects with POA-PIs had a mean age of 72.7 ± 15.4 years; 52.4% were male, 80.3% white, 30.9% lived alone, 99.2% were insured, and 30.6% were college educated. They presented with a mean of 1.46 PIs; 37.5% were full thickness. Admission Braden Scale for Pressure Sore Risk scores indicated that 77% were at risk for PI; subscores indicated mobility limitations in 90.8% and inadequate/poor nutrition in 41.3%. Subjects had multiple comorbid conditions (mean 18.4 ± 5.3 admission diagnoses). Only 21.4% were receiving home care services prior to admission. More than half (51.5%) were discharged to a healthcare facility, 33% to home, and 14% died or received hospice care. The 30-day readmission rate was 15.5%. CONCLUSION: The overall prevalence of POA-PIs on hospital admission in this study was higher than previous published reports. The majority arrived from community-dwelling locations. The severity of community-dwelling POA-PIs was higher than known benchmarked hospital-acquired PI severity. This real-world profile of community-dwelling patients with PI suggests that these individuals are considerably vulnerable and underserved by home care services. Opportunities exist for community PI screening, prevention, and intervention.

Peripheral Tibial Nerve Stimulation for Overactive Bladder Syndrome: Treatment Success and Patient Satisfaction.

OBJECTIVE: To evaluate the success rate and patient satisfaction ofperipheral tibial nerve stimulation (PTNS) therapy. METHOD: Retrospective cohort study assessing PTNS treatment success and patient satisfaction. RESULTS: Data from 34 women were included. On average, patients were 70.2 (± 12) years of age, had a BMI of 29.9 (± 8.9) kg/M², and traveled 11.2 (± 12.3) miles to receive weekly PTNS treatments. Overall, 22 patients (64.7%) were satisfied, four (11.8%) unsatisfied, and eight (23.5%) undecided. Those who were satisfied completed an average of 10.9 treatments (± 2.4), those who were unsatisfied completed an average of 9.5 treatments (± 2.6), and those left undecided completed an average of 7.2 treatments (± 4.3). The fourth treatment visit was the most likely to predict whether a patient would be satisfied or unsatisfied by the 12th treatment. CONCLUSION: Overall the success of the PTNS therapy was 64.7%, consistent with previous studies. Most patients note improvement after the fourth treatment.

Single-shot terahertz time-domain spectroscopy in pulsed high magnetic fields.

We have developed a single-shot terahertz time-domain spectrometer to perform optical-pump/terahertz-probe experiments in pulsed, high magnetic fields up to 30 T. The single-shot detection scheme for measuring a terahertz waveform incorporates a reflective echelon to create time-delayed beamlets across the intensity profile of the optical gate beam before it spatially and temporally overlaps with the terahertz radiation in a ZnTe detection crystal. After imaging the gate beam onto a camera, we can retrieve the terahertz time-domain waveform by analyzing the resulting image. To demonstrate the utility of our technique, we measured cyclotron resonance absorption of optically excited carriers in the terahertz frequency range in intrinsic silicon at high magnetic fields, with results that agree well with published values.

Comparison of Weight-Based Dose vs. Standard Dose Diltiazem in Patients with Atrial Fibrillation Presenting to the Emergency Department.

BACKGROUND: Despite evidence-based recommended weight-based (WB) dosing of diltiazem for the initial treatment of atrial fibrillation (AF) with rapid ventricular response (RVR), many providers utilize lower initial doses of diltiazem. OBJECTIVE: We sought to determine whether a low, standard dose of diltiazem is noninferior to WB diltiazem as an initial bolus dose in the treatment of AF with RVR. METHODS: This retrospective review included patients who presented to the emergency department (ED) of an urban, academic tertiary medical center experiencing AF with RVR from November 2010 to August 2014. Adult patients were categorized by the dose of diltiazem received; 10 mg standard dose or 0.2-0.3 mg/kg WB dose. The primary outcome of successful treatment was defined as a composite of the following parameters 15 min after the initial bolus dose: heart rate (HR) < 100 beats/min, reduction of HR ≥ 20%, or a conversion to normal sinus rhythm. RESULTS: Four hundred and fifty-six patients who received diltiazem were included for study evaluation (standard dose: n = 255 patients, WB: n = 201 patients). Baseline characteristics, medical history, and medication use before ED presentation were similar between the groups. Significant differences at baseline between the groups included weight and HR at presentation. The primary outcome of successful treatment was attained in 60.8% of the standard dose patients and 68.7% of the WB patients (p = 0.082). CONCLUSIONS: In patients presenting to the ED, we found that standard dose diltiazem was noninferior to WB dosing in the initial treatment of AF with RVR.

A multi-center assessment of the temporal trends in myocardial perfusion imaging.

BACKGROUND: Recent literature suggests that the frequency of abnormal SPECT myocardial perfusion imaging (MPI) has decreased over the past two decades despite an increase in the prevalence of many cardiac risk factors. This study examined the trends in the prevalence of obstructive coronary artery disease (CAD) by abnormal and ischemic MPI and invasive angiography. METHODS: We analyzed all patients who underwent stress MPI or invasive angiography at two academic centers between January 1996 and December 2012, for their demographic data and study results. RESULTS: A total of 108,654 MPI studies were performed. Over time, the percentage of patients with hypertension, hyperlipidemia, diabetes, and a history of smoking increased. There was a decline in the prevalence of abnormal MPI studies in all patients as well as in those with and without known CAD (from 47.2%, 71.8%, and 31.4% in 1996 to 33.9%, 64.8%, and 18.8% in 2012, respectively, all P < .0001). Similarly, there was a decline in the prevalence of ischemic MPI studies in all patients as well as in those with and without known CAD. A total of 142,924 invasive angiograms were performed. There was a decline in the prevalence of one-vessel and multi-vessel coronary disease (from 29.1% and 53.6% in 1996 to 22.4% and 35.9% in 2012, respectively, all P < .0001). CONCLUSIONS: There has been a temporal decline in the prevalence of abnormal and ischemic MPI studies as well as the frequency and extent of obstructive CAD on angiography. However, this decline was not to the same extent as previously reported, and the overall 34% abnormal MPI rate, with 19% in patients with no known CAD and 65% in patients with known CAD, remains a clinically relevant percentage of patients tested.

Trends in sacral colpopexy for the management of apical prolapse.

OBJECTIVE: To evaluate trends in surgical approach for sacral colpopexy since the advent of robotic technology for gynecologic procedures. STUDY DESIGN: Women who underwent surgery for uterovaginal prolapse, cystocele, and/orvaginalvault prolapse were included in this study. The number of patients undergoing a vaginal approach for prolapse was compared to the number of patients receiving sacral colpopexy. Descriptive statistics comprised means and standard deviations, while categorical data were reported as frequencies. Inferential statistics comprised Student's t-test for assessing two-group differences between means ofcontinuous, normally distributed data and chi-squared tests for comparisons of equality of distribution between categorical variables. RESULTS: Patients undergoing sacral colpopexy were younger than their vaginal surgery counterparts (P< 0.001). When stage ofprolapsewas dichotomized, among those with stage 1-2 prolapse, a greater percentage of patients received colpopexy in favor of vaginal surgery in 2010 than in 2007 (P=0.001). CONCLUSION: There is an increasing trend towards robotic-assisted sacralcolpopexyforthe management of apical prolapse.

Evaluation of Timing of Antimicrobial Surgical Prophylaxis on Rates of Surgical Site Infections.

Background: Surgical site infections (SSIs) are common healthcare-associated infections, and national guidelines recommend that antimicrobial prophylaxis (AP) be administered 60 min prior to incision. However, there are limited data regarding the "most optimal" time for administration within the 60-min window. Patients and Methods: This was a multicenter, retrospective study of adult (≥18-year-old) patients that underwent an abdominal hysterectomy, colorectal surgery, or craniotomy and received AP within 60 min of incision. Incidence of SSI was compared between patients who received AP 0-30 versus 31-60 min of incision. In addition, a predefined subgroup analysis evaluated incidence of SSI for 15-min intervals within the 60-min timeframe. Results: Of the 277 patients included in the primary analysis, 233 (84.1%) and 44 (15.9%) received AP 0-30 min and 31-60 min prior to incision, respectively. SSIs were documented in 6.0% (14/233) versus 4.5% (2/44) of patients in the primary analysis (p = 0.703). In the secondary analysis, 137 (49.5%), 95 (34.3%), 34 (12.3%), and 11 (4.0%) patients received AP 0-15, 16-30, 31-45, and 46-60 min prior to incision, respectively. There was no difference in incidence of SSIs among the 15-min intervals (4.4% vs. 8.4% vs. 2.9% vs. 9.1%, p = 0.487). Of the 16 patients in this study that incurred a SSI, 5 patients had positive cultures, of which 3 contained bacteria that proved to be resistant to the antibiotic used for AP. Conclusions: The results of our analysis support current national guidelines. Future investigation of different intervals (e.g., AP 15-45 min prior to incision) may be beneficial on the basis of pharmacokinetics of routinely prescribed AP.

The Impact of Vaginal Probiotics on Pessary Use: A Randomized Controlled Trial.

IMPORTANCE: Pessary-related adverse effects are common, and treatment options are limited. Probiotics may improve pessary-related adverse effects by altering the vaginal microenvironment. OBJECTIVE: This study aimed to evaluate the effect of a vaginal probiotic suppository on the vaginal microenvironment among pessary users. STUDY DESIGN: Women who used pessaries were randomized to vaginal probiotic suppository use versus without use. The intervention was a vaginal probiotic suppository and moisturizing vaginal gel. The vaginal microenvironment was assessed using Gram stain and Nugent's criteria at baseline and 3 months by a microbiologist blinded to group allocation. Symptoms and experience with use of the probiotic were assessed using questionnaires. The primary outcome was change in lactobacilli count on Nugent subscore at 3 months. RESULTS: A total of 147 postmenopausal women were randomized (86 to the intervention arm and 61 to the control arm), and 124 (87.9%) presented for a 3-month follow-up. There was no difference between the arms in age, race, body mass index, and Charlson Comorbidity Index. A majority of participants had the pessary managed by the health care professional (intervention arm vs control arm, 46 [76.7%] vs 55 [68.8%]; P = 0.30). Composition of the vaginal microenvironment did not differ with or without probiotic treatment at 3 months. Bother from vaginal symptoms, including discharge, itching, and discomfort, did not differ between arms. Adverse effects from the intervention were minor, resolved with discontinuation, and occurred at 39.1%. CONCLUSION: Vaginal probiotic suppository use did not affect the composition of the vaginal microenvironment, patient satisfaction, or vaginal symptoms after 3 months of use in pessary users.